Surgical management of hypoplastic left heart syndrome at the Birmingham Children's Hospital.

Currently, a three-stage surgical palliation remains the treatment of choice at Birmingham Children's Hospital. After initial introduction of the classical Norwood with pulmonary blood flow provided by a modified Blalock-Taussig shunt, a right ventricular to right pulmonary artery conduit at stage 1 Norwood palliation is now used in most cases, a bi-directional 'Glenn' shunt at second stage and an extra-cardiac Fontan completion at third stage. Mortality and morbidity has improved after modification of the technique. Thirty-day mortality was 32.4% (79/244) for the 'classical' Norwood procedure, 25.0% (7/28) for the left-sided RV-PA conduit and 12.7% (22/173) for the right-sided RV-PA conduit. Interstage mortality was 8.6% (21/244) for the 'classical' Norwood procedure, 14.3% (4/28) for the left and 10.1% (15/148) for right-sided RV-PA conduit. After stage II, 30-day mortality was 3.0% (10/335) for all groups. Stage III 30-day mortality was 0.9% (1/115) for all groups.

Three-dimensional echocardiography for planning of mitral valve surgery: current applicability?

BACKGROUND: Two-dimensional transesophageal echocardiographic (2D TEE) assessment of the mitral valve requires mental integration of a limited number of 2D imaging planes. Structural display in three dimensions from any perspective may be of advantage to the surgeon for better judgment and planning. METHODS: Feasibility, accuracy, and limitations of preoperative three-dimensional transesophageal echocardiography (3D TEE) was assessed in 51 patients with mitral valve disease. The width of the anterior mitral valve was measured with either method and compared with the operative finding. Three-dimensional dynamic sequences of the reconstructed mitral valve were shown preoperatively to the surgeon and later compared with the intraoperative finding. RESULTS: The quality of the 3D reconstruction was graded as good in 25 patients (49.0%), fair in 16 patients (31.4%), and poor in 10 patients (19.6%) where atrial fibrillation did not allow ECG gating. Thirty-nine patients had successful mitral valve repair and twelve patients required valve replacement. Based on intraoperative findings, sensitivity for the diagnosis of mitral valve prolapse using 2D TEE and 3D TEE was 97.7% and 92.9% (p = ns) respectively and specificity was 100% by both methods. Sensitivity for the diagnosis of rupture of chordae tendineae using 2D TEE and 3D TEE was 92.3% and 30.8% respectively (p < 0.05) and specificity was 100% by both methods. CONCLUSIONS: Dynamic 3D echocardiography is feasible and can provide good insight into valvular motion and allows adequate preoperative planning when reconstruction is being considered. However dynamic 3D reconstruction is currently limited by the quality of the original 2D echo cross sectional images which can be adversely affected by minimal patient movements, breathing, or cardiac arrhythmia, thus limiting accuracy of the 3D TEE significantly compared with 2D TEE.

Skeletonization versus pedicle preparation of the radial artery with and without the ultrasonic scalpel.

BACKGROUND: The radial artery (RA) is increasingly used for myocardial revascularization because of its presumed advantageous long-term patency rates. The vessel can be harvested as a pedicle or skeletonized. The aim of this study was to compare the skeletonization technique with pedicle preparation using either an ultrasonic scalpel or scissors. METHODS: Forty consecutive patients with coronary artery disease undergoing complete arterial revascularization were included in the study. In 20 patients the RAs were prepared using scissors and clips (group 1: skeletonization; group 2: pedicle). In another 20 patients the arteries harvested were prepared using an ultrasonic scalpel (group 3: skeletonization; group 4: pedicle). The RA was treated with papaverine to prevent spasm of the vessel during and after harvesting. Tissue specimens of each RA were taken to analyze endothelial morphology by scanning electron microscopy. After implantation of the RA, graft perfusion was measured with a flow probe. RESULTS: Harvesting the RA as a skeletonized vessel took more time as compared with pedicle preparation (group 1 vs group 2: 37.1 +/- 3.5 minutes vs 24.4 +/- 3.9 minutes; p < 0.001 and group 3 vs group 4: 31.1 +/- 3.5 minutes vs 25.6 +/- 3.7 minutes; p < 0.01). The number of hemostatic titanium clips was similarly higher in group 1 as opposed to group 2 (58.7 +/- 7.1 vs 38.7 +/- 7.1; p < 0.01). However, there was no difference between groups 3 and 4 (p = 0.086). The length of the RA after skeletonization with scissors and clips was 20.8 +/- 1.5 cm in contrast with 19.1 +/- 0.9 cm (p < 0.01) after dissection as a pedicle. In the groups using the ultrasonic scalpel, there was no difference in graft length (p = 0.062). Mean blood flow through the graft after establishing the proximal anastomosis was similar among all groups (groups 1, 2, 3, and 4: 50 +/- 20.1 mL/min, 53.8 +/- 24.3 mL/min, 56.3 +/- 25.1 mL/min, and 51.8 +/- 23 mL/min, respectively). Scanning electron microscopy demonstrated endothelial damage in all patients in groups 1, 2, and 3 and in 7 patients of group 4. Most endothelial lesions were minor except in group 3 in which 1 of 5 endothelial lesions were severe. Statistically significant differences was found between groups 1 and 2, and 3 and 4 with respect to the degree of endothelial damage (p < 0.01). CONCLUSIONS: Skeletonization using scissors and clips is more time consuming and technically more difficult, but yield significantly longer grafts. Skeletonization with an ultrasonic scalpel did not result in additional length and was more frequently associated with severe endothelial damage. Pedicle preparation using scissors or an ultrasonic scalpel is much simpler and faster, and does not jeopardize endothelial integrity.

Intraoperative left atrial ablation (for atrial fibrillation) using a new argon cryocatheter: early clinical experience.

PURPOSE: Recently surgical treatment of atrial fibrillation has gained more popularity and presently is being performed in large numbers of patients. This report describes our early experience in treatment of patients with chronic or paroxysmal atrial fibrillation with a new tool for left atrial cryoablation. DESCRIPTION: From July 2002 through January 2003, 28 patients underwent left atrial cryoablation with the Surgifrost CryoCath. Patients underwent cryotherapy as an isolated procedure (n = 1), in combination with mitral valve surgery (n = 13), or with other surgical procedures (n = 14). In all patients contiguous lesion lines to the orifices of the pulmonary veins connected to the mitral annulus and the atriotomy were created. Surgery was performed through a conventional sternotomy in 8 patients (29%) and a right lateral minithoracotomy using video-assistance in 20 patients (71%). EVALUATION: Postoperatively sinus rhythm was restored in 27 patients (96%). At discharge 82% (23/28) of patients were in sinus rhythm and 18% (5/28) were in atrial fibrillation. Four patients (14%) required pacemaker implantation. There was no in-hospital mortality. At 6-months follow-up (19/28 patients) all were alive and 74% were in stable sinus rhythm, New York Heart Association functional class was 1.2 +/- 0.4. CONCLUSIONS: As indicated by our small and early patient cohort left atrial cryoablation with the Surgifrost argon cryocatheter is effective for the treatment of atrial fibrillation. This new device is technically easy to handle, it can be applied through a median sternotomy or lateral minithoracotomy. Long-term follow-up is necessary to evaluate further rhythm outcome.

Curative treatment of atrial fibrillation with intraoperative radiofrequency ablation: short-term and midterm results.

OBJECTIVE: This report describes the early and midterm results after intraoperative radiofrequency ablation of atrial fibrillation for patients with isolated chronic atrial fibrillation or atrial fibrillation in combination with additional valvular and nonvalvular cardiac diseases. METHODS: From August 1998 to March 2001, a total of 234 patients with chronic atrial fibrillation underwent isolated intraoperative radiofrequency ablation alone (n = 74, 31.6%) or in combination with other cardiac procedures, such as mitral valve reconstruction (n = 57, 24.4%), mitral valve replacement (n = 38, 16.2%), aortic valve replacement (n = 11, 5.1%), coronary artery bypass grafting (n = 8, 5.0%), or a combination of the last with other cardiac procedures (n = 46, 19.7%). In all cases anatomic reentrant circuits confined within the left atrium were eliminated by placing contiguous lesion lines involving the mitral anulus and the orifices of the pulmonary veins through the use of radiofrequency energy application (exposure time, 20 seconds). A median sternotomy was used in 101 cases (43.2%), and video assistance through a right lateral minithoracotomy was used in 133 cases (56.8%). RESULTS: A total of 188 patients (83.9%) were discharged in sinus rhythm, 17 patients (7.6%) had atrial fibrillation, and 19 patients (8.5%) had atypical flutter. Pacemakers were implanted in 23 patients (9.8%). There were 10 in-hospital deaths (4.2%), and 30-day mortality was 5 patients (2.1%). In 3 cases (1.3%) an atrioesophageal fistula developed, necessitating surgical repair. Six months' follow-up was complete for 122 (61.0%) of 200 patients, with 99 patients still in stable sinus rhythm (81.1%, 95% confidence interval 73.1%-89.9%). Twelve months' follow-up was complete for 80 (90.9%) of 88 patients, with 58 patients still in sinus rhythm (72.5%, 95% confidence interval 61.3%-83.2%). CONCLUSIONS: Intraoperative radiofrequency ablation is a curative procedure for chronic atrial fibrillation. It is technically less challenging than the maze procedure and can be applied through a minimally invasive approach. Protection of the esophagus seems mandatory to avoid the deleterious complication of a left atrioesophageal fistula, such as was observed in 3 cases.